Speed, sex, gay men, and HIV: ecological and community perspectives

Turning points, identity, and social capital: A meta-ethnography of methamphetamine recovery

BACKGROUND

Despite the increasing prevalence and distinct nature of methamphetamine-related harms, treatment models are limited, and relapse is common. Meta-ethnography has been increasingly used to synthesise qualitative health research and develop new concepts or theories. This meta-ethnography aimed to explore methamphetamine users' experiences of cessation, recovery, and relapse, to better understand how to tailor support for this population.

METHODS

A systematic review was conducted of six electronic databases, supported by hand searches of leading journals and reviews of reference lists. Reports were included that used naturalistic participant observation to examine methamphetamine cessation, recovery, and relapse with at least 50% of their sample. The life course approach to drug use was used to inform the process of data analysis and interpretation. The final sample was synthesised using Reciprocal Translation supported by open and axial coding.

RESULTS

Nineteen sources were selected, thirteen of which were conducted in the United States. Two themes were identified: methamphetamine users are exposed to a range of relapse triggers, but also triggers for recovery, and their susceptibility to these triggers is largely determined by their social environment; and the process of recovery requires changes in personal and social identity which can be a barrier to recovery for some users.

CONCLUSION

These findings present the concept of recovery triggers and highlight the role of wider risk environments in determining methamphetamine recovery, and the negative potential of social capital. These themes also address the ongoing debate regarding the agency of drug users, and the impact of this debate on drug user's experiences of recovery.

The Changing Burden of HIV Attributable to Methamphetamine Among Men Who Have Sex with Men in King County, Washington

Methamphetamine use is a key driver of HIV transmission among men who have sex with men (MSM). We evaluated trends in incident HIV diagnosis rates among methamphetamine using and nonusing MSM and assessed the relationship between methamphetamine use and demographic, behavioral, and clinical characteristics among MSM newly diagnosed with HIV. We analyzed several sources of HIV and behavioral surveillance data to estimate incident rates of HIV diagnoses and the population attributable risk percent corresponding to methamphetamine use among MSM in King County, Washington. Missing values were recovered through multiple imputation. We report descriptive statistics and adjusted odds ratios yielded from multivariable logistic regression models. Between 2010 and 2015, the HIV diagnosis rate among methamphetamine-using MSM declined from 31.2 to 11.5 per 1000 MSM (vs. 6.4-3.9 per 1000 MSM overall), and the percent of new diagnoses attributable to methamphetamine use declined from 25% to 13%. During the same period, methamphetamine use among HIV-negative MSM remained relatively stable. Among MSM newly diagnosed with HIV, methamphetamine-using MSM were more likely to be unstably housed (24% vs. 6%), to have engaged in transactional sex (19% vs. 4%), and to have had female partners (17% vs. 10%). Methamphetamine-using MSM were less likely to be virally suppressed at 6 (31% vs. 54%) and 12 (59% vs. 73%) months following an HIV diagnosis. The declining HIV diagnosis rate among methamphetamine-using MSM is encouraging, but this subgroup continues to have considerable HIV risk and health disparities.

Reducing HIV Infections at Circuit Parties: From Description to Explanation and Principles of Intervention Design

Circuit parties are weekend-long, erotically charged, drug-prevalent dance events attended by up to 25 000 self-identified gay and bisexual men who socialize and dance nonstop, sometimes for 24 hours or longer. Although these parties started originally as part of the gay community’s response to raise HIV/AIDS awareness and to build community and cultural identity, they may have become a site for transmitting HIV across geographical regions and socioeconomic groups of gay and bisexual men. This article reviews the descriptive published studies on circuit parties. The authors use these studies and the literature on drug use and high-risk sexual behavior in gay and bisexual communities, along with sociological and social psychological research, to propose a causal model of why circuit parties may contribute to unsafe sexual practices that increase HIV infection risk. The authors abstract 5 prevention messages relevant to circuit parties and review intervention studies in nonparty settings for insight into how to reduce risky sexual behavior within circuit events. These intervention studies help to identify 5 context-specific groups that can effectively carry the prevention messages. The 5-by-5 matrix represents a first stage in developing a causal model for reducing HIV infections, along with evaluable principles of intervention, at circuit parties.

Effects of alcohol cues and alcohol intoxication on drug use expectancies among men who have sex with men

Although alcohol and drug use have been identified as HIV-risk factors for men who have sex with men (MSM), little is known about how they interact. An alcohol administration paradigm was used to examine alcohol's cue and pharmacological effects on perceived drug use benefits and consequences in 117 MSM. Planned contrasts indicated that those in the alcohol cue (i.e., placebo) condition reported lower perceived drug consequences compared to controls. No cue effects were found for drug benefits. There was no pharmacological effect of alcohol as compared to alcohol cue on either outcome. Findings suggest that alcohol cues may influence the perception of consequences related to drug use, which has implications for health interventions targeting substance use and HIV risk.

Breaking the bond between stimulant use and risky sex: a qualitative study

Stimulant-using men who have sex with men (MSM) are at increased risk for human immunodeficiency virus (HIV) transmission, and are more likely to practice unprotected anal sex than MSM who do not use methamphetamine and/or crack cocaine. In this paper the authors report on interviews with stimulant-using men who have sex with men who have participated in Crystal Meth Anonymous and other 12-step groups, focusing on those who did not have unprotected anal intercourse during a 6-month follow-up period and their reasons for doing so. The authors find 4 common themes cited: a diminished sexual drive; exclusive sex with a primary partner; greater sense of responsibility/commitment to safer sex; and most commonly of the four, an overall healthier sex life. Participants' use of terms such as "healthy," "enjoyable," and "fulfilling" to describe sex not on stimulants, and avoidance of these terms for sex on stimulants, suggests a distinct dimension of sexual experience.

Correlates of intensive alcohol and drug use in men who have sex with men in Catalonia, Spain

BACKGROUND

The objectives of the study were to determine the prevalence of alcohol and drug use before or during sex among men who have sex with men (MSM) in Catalonia during 2006, and to identify factors associated with variables of intensive alcohol and drug use.

METHODS

Cross-sectional study using self-administered questionnaires. Men were recruited in saunas, sex shops, bars and a public park and by mail to all the members of the Catalonia Gay Federation.

RESULTS

19.6% of men said they were frequent users of alcohol, some type of drug (21.7%), or that they were multidrug users (18%) in the last 12 months. The multivariate analysis showed an association between having suffered discrimination and frequent alcohol and multidrug use. Being human immunodeficiency virus (HIV)-positive was associated with frequent use of drugs and multidrug use. Associations between substance use and sexual risk behaviour also emerged.

CONCLUSION

The high percentage of MSM who use alcohol and drugs before and during sex and association between these substances and sexual risk behaviours reveals the need to intensify interventions to reduce their levels of use and/or to reduce the associated damage and risks. These programs must try to cover MSM-specific psychosocial aspects and include prevention for HIV-positive men.

Rapid assessment of drug-related HIV risk among men who have sex with men in three South African cities

The current assessment was undertaken to examine the link between drug use and sexual risk behavior among men who have sex with men (MSM) in locations known to have high prevalence rates of drug use and sexual risk behavior in Cape Town, Durban and Pretoria, South Africa. Street intercepts and purposive snowball sampling were used to recruit drug-using MSM. A rapid assessment was undertaken which included observation, mapping, key informant interviews and focus group interviews with MSM. Drug using key informants were tested for HIV. The use of drugs like crack cocaine, cannabis and methamphetamine to specifically facilitate sexual encounters was evident. Drugs led to inconsistent condom use and other high-risk sexual activities despite HIV risk knowledge being high. Many injecting drug-using MSM shared needles and reused equipment. Among MSM who agreed to HIV testing, one-third tested positive. Views about drug and HIV treatment and preventive services and their efficacy were mixed. Various barriers to accessing services were highlighted including homosexual stigmatization and availability of drugs in treatment facilities. Recommendations include addressing the gap between HIV-risk knowledge and practice, extending VCT services for MSM, increasing the visibility of drug abuse services within communities, addressing concerns about drug availability in treatment centers as well as reintegration issues and the need for after-care services, reducing stigmatization in drug and HIV services for MSM and finally, strengthening the link between drug treatment services and HIV prevention by integrating HIV/drug-related risks into HIV prevention efforts and HIV risks into drug use prevention efforts.

Sex Workers, Fem Queens, and Cross-Dressers: Differential Marginalizations and HIV Vulnerabilities Among Three Ethnocultural Male-to-Female Transgender Communities in New York City

This article describes 3 distinct ethnocultural male-to-female transgender communities in New York City: the low-income African American/Black and Latina(o) House Ball community; low-income, often undocumented immigrant Asian sex workers; and middle-class White cross-dressers. These communities are highly socially isolated from each other and are more connected to their ethnocultural contexts than to an abstract and shared transgender identity. Whereas previous research either has viewed male-to-female transgender people as one monolithic group or has separated them into abstract racial categories unconnected to their communities and lifestyles, this article positions them within specific social networks, cultures, neighborhoods, and lifestyles. With regard to HIV vulnerabilities, violence, and rape, House Ball community members seemed to engage in the riskiest form of survival sex work, whereas Asian sex workers seemed to engage in moderate-risk survival sex work. White cross-dressers seemed to engage in very low-risk recreational sex work.

Methamphetamine Use and Risky Sexual Behaviors During Heterosexual Encounters

OBJECTIVE

This study examined the association between event-level methamphetamine use and heterosexual risk behaviors.

METHOD

Data on 1213 heterosexual encounters were collected using audio-computer assisted self interviews from 703 injecting drug users in North Carolina. Data were obtained by asking participants a series of questions about the last time that they had sex (oral, vaginal, and/or anal). Although participants were interviewed at up to 3 time points, data were analyzed at the event level rather than as longitudinal because we were interested in the co-occurrence of methamphetamine use and sexual risk behaviors. Multivariate generalized estimating equations models were developed to examine the association between co-occurring methamphetamine use and each of 6 heterosexual risk behaviors.

RESULTS

Methamphetamine was used in 7% of encounters. Methamphetamine use by either or both partners was associated with an increased likelihood of anal intercourse (odds ratio [OR] = 2.41, 95% confidence interval [CI] = 1.29-4.53), vaginal and anal intercourse (OR = 2.41, 95% CI = 1.22-4.77), and sex with a new partner (OR = 1.98, 95% CI = 1.09-3.61). In addition to these behaviors, methamphetamine use by both partners was also significantly associated with unprotected intercourse with a new partner (OR = 5.20, 95% CI = 2.09-12.93) and unprotected anal intercourse (OR = 4.63, 95% CI = 1.69-12.70).

CONCLUSIONS

Methamphetamine use during heterosexual encounters appears to increase sexual risk-taking, especially when both partners are using it.

Unprotected anal intercourse and substance use among men who have sex with men with recent HIV infection

OBJECTIVES

To examine within-subjects and combined between- and within-subjects associations between substance use and unprotected anal intercourse (UAI) among men who have sex with men (MSM) with recent HIV infection.

METHODS

One hundred ninety-four MSM who were recently infected with HIV completed a computer-assisted questionnaire regarding sexual behaviors and substance use with their last 3 partners. Associations between UAI and substance use were assessed using conditional logistic regression (CLR) to assess associations among the 116 MSM reporting UAI with some but not all partners and generalized linear mixed effects models (GLMMs) to examine a combination of within- and between-subjects associations in the entire sample (N = 194).

RESULTS

In multivariate CLR models and GLMMs, UAI was associated with the use of methamphetamine (odds ratio [OR] = 4.9 and OR = 3.5, respectively), marijuana (OR = 4.0 and OR = 2.2, respectively) and erectile dysfunction medications (EDMs) when used with a main partner (OR = 13.8 and OR = 10.1, respectively).

CONCLUSIONS

Results indicate that a direct association may exist between specific substances and UAI and provide evidence that the use of methamphetamine and EDMs may contribute to HIV transmission.

Stimulant use and HIV risk behavior: the influence of peer support group participation

This study examines 12-step groups for recovery from methamphetamine and cocaine use that are attended by men having sex with men and the impact of attendance on HIV risk behavior. Participants in Crystal Meth Anonymous and other 12-step groups were interviewed up to 3 months since their last substance use. Sixty-two initial interviews, and ethnographic observations, were conducted. With entry into the program, mean reported sexual partners fell from around seven to one per month and the proportion having unprotected anal intercourse declined from 70% to 24%. HIV-positive men were more likely than HIV-negative men to report unprotected anal intercourse when using stimulants but less likely in recovery. Qualitative data suggest a transition from cocaine to methamphetamine in Chicago, and that reduction in partners is due to fear of relapsing in sexual situations rather than program teachings. These programs do however facilitate discussions around drug use and sexual issues.

Crystal methamphetamine and sexual sociality in an urban gay subculture: an elective affinity

This paper draws on 49 qualitative interviews to explore the contextual antecedents of methamphetamine use in a sample of gay and bisexual Manhattan men. The paper distinguishes itself from the public health literature on crystal methamphetamine use in this population by shifting the analytic focus from individual-level factors of drug use to the role of social context. While individual-level factors--including self esteem and social awkwardness--are related to methamphetamine use, we argue that these factors arise in and are exacerbated by interactional pressures attendant to Manhattan's gay sexual subculture, which revolve around the expectation of peak sexual performance. Because methamphetamine is associated with increased self-esteem, increased libido, greater sexual endurance, diminished sexual inhibition, and a higher threshold for pain, the drug is used strategically by gay and bisexual men to negotiate sexual sociality and increase sexual pleasure. Hence, we suggest that there exists an elective affinity between Manhattan's gay sexual subculture and the particular pharmacological effects of methamphetamine-whereby the former strongly favours the latter as a systematic pattern of response. In turn, this relationship is linked to unsafe sexual practices or the social conditions that put gay men 'at risk of risk' of HIV infection.

Club drugs as causal risk factors for HIV acquisition among men who have sex with men: a review

We reviewed medical and psychology databases for articles published between January 1980 and August 2005 demonstrating associations between HIV/Sexually Transmitted Infection risk and club drug use. Seventy-four articles were reviewed, of which 30 provided adjusted risk ratios for associations between HIV/sexually transmitted infection risk and club drug use among men who have sex with men. Definitions and lists of club drugs were broad and inconsistent. We constructed a conceptual framework of biologically plausible pathways for causation. Using Hill's criteria to examine club drugs as causal risk factors for HIV, we found the most evidence for methamphetamine and volatile nitrites; however, more studies are needed.

Crystal methamphetamine and ecstasy differ in relation to unsafe sex among young gay men

OBJECTIVE

Poly-substance use in gay social ('club') settings is common. Recent studies suggest a link between 'club' drug use and sexual risk behaviours. In this qualitative study, we compare and contrast two 'club' drugs: crystal methamphetamine and ecstasy (MDMA).

METHODS

Life history interviews were conducted with 12 HIV seroconverters and 12 age-matched controls recruited from a prospective cohort study of young gay and bisexual men in Vancouver, British Columbia. Textual data concerning illicit substance use and unsafe sex were analyzed using NUDIST software.

RESULTS

Most men related a substantial knowledge of and experience with crystal and ecstasy. Both drugs had attributes that enhanced gay socialization and were used in the same venues. Crystal was used to remain awake and increase energy. Ecstasy was used to induce euphoria and group connectedness. However, unlike ecstasy, crystal was associated with a distinct pattern of sexual arousal that frequently included unprotected (sometimes group) sex, was more likely to be used regularly by HIV-positive men, and was reportedly highly addictive and problematic.

CONCLUSION

Crystal and ecstasy are used in the same social venues but differ markedly in relation to sexual risk behaviour.

Substance use, substance choice, and unprotected anal intercourse among young Asian American and Pacific Islander men who have sex with men

Substance use has been shown to be an important factor associated with having unprotected anal intercourse (UAI) among Asian and Pacific Islander (API) men who have sex with men (MSM). However, little is known about which substances are used in conjunction with sexual activity and whether having UAI varies by substance choice in this population. From January 2000 to September 2001, we sampled API MSM aged 18-29 years from 30 gay-identified venues in San Francisco, California, and interviewed 496 API men face-to-face using a standardized questionnaire. Overall, 47% of the sample reported UAI in the past 6 months. During the same time period, 32% and 34% reported being "high" or "buzzed" on alcohol and drugs during sex, respectively. The most common drugs used in conjunction with sex were methylenedioxymethamphetamine ("ecstasy"; 19%), followed by marijuana (14%), inhalant nitrites ("poppers"; 11%), and crystal methamphetamine ("crystal"; 10%). In a multivariate model, we observed associations between UAI and being high or buzzed on ecstasy (odds ratio [OR] = 2.62; 95% confidence interval [CI] = 1.37, 5.02) and poppers during sex (OR = 3.29; 95% CI = 1.50, 7.25). However, being high or buzzed on alcohol, marijuana, gamma-hydroxybutyrate (GHB), and crystal methamphetamine during sex had no association with UAI. One third of sampled young API MSM used drugs or alcohol during sex. The co-occurrence of ecstasy and popper use and unprotected sex underscores the need to develop HIV prevention programs focusing on particular drugs.

Longitudinal patterns of methamphetamine, popper (amyl nitrite), and cocaine use and high-risk sexual behavior among a cohort of san francisco men who have sex with men

Most prior studies examining drug use among men who have sex with men (MSM) have been cross-sectional or retrospective and have not determined whether periods of increased drug use are associated with high-risk sexual behavior at the individual level. In this article, we describe patterns of use of methamphetamines, poppers, and sniffed cocaine and sexual risk behavior among 736 San Francisco MSM enrolled in the EXPLORE study and followed for up to 48 months. In longitudinal analysis, use of methamphetamines, poppers, and sniffed cocaine declined during follow-up. However, compared with older participants, younger participants were more likely to increase their drug use over time. Results of conditional logistic regression demonstrated that high-risk sexual behavior was more common during reporting periods characterized by increased methamphetamine, poppers, or sniffed cocaine use. This within-person analysis found that compared with periods of no drug use, periods of both light drug use (less than weekly use of drugs) and heavier drug use (at least weekly use of at least one drug) were significantly associated with increased risk of engaging in unprotected anal sex with an HIV-positive or unknown-status partner. These results suggest that even intermittent, recreational use of these drugs may lead to high-risk sexual behavior, and that, to reduce and prevent risks of HIV, no level of use of these drugs should be considered "safe." HIV prevention interventions should target MSM who report either light or heavy use of methamphetamines, poppers, and sniffed cocaine.

Epidemiology of MDMA and associated club drugs in the Seattle area

Club drug use, MDMA in particular, appeared as a growing problem in the Seattle area in the late 1990s. To understand more about the patterns of MDMA use and to evaluate the current state of MDMA use, multiple data sources were examined. The seven data sources utilized included local community-based club drug surveys collected in 2003 at raves, treatment agencies, and gay-oriented bars and sex clubs; school surveys (collected in 2002); mortality data (deaths between 2000 and 2002); data from the sexually transmitted disease clinic (October 2002 to October 2003); focus groups (2003) with men who have sex with men; emergency department drug mentions (1995 to 2002); and drug treatment admissions (1999 to 2003). Taken together, these data indicate moderate levels of MDMA use and relatively low levels of mortality and acute morbidity. However, there are several areas of concern including possible mental health effects and high levels of suspected adulteration of MDMA. Some data point to a relationship between MDMA use and risky behaviors including unprotected sex. Implications for prevention, intervention, and treatment are discussed.

Heart disease, methamphetamine and AIDS

Methamphetamine (MA) not only affects the nervous system but also has cardiac toxicity and immunosuppressive properties. This manuscript will provide support that there is a relationship between MA use and heart disease as well as immune dysfunction. The cardiovascular manifestations of acute MA use include tachycardia, atrioventricular arrhythmias, myocardial ischemia, myocardial ischemia and hypertension, resulting in cardiac lesions. Chronic use of MA causes cardiomyopathy including cellular infiltration, myocardial hypertrophy, myocardium rupture and fibrosis. The increased catecholamine levels are responsible for the cardiac lesions induced by MA. The additional problem with MA use is its potential to disrupt the immune system function leading to suppression of mitogen-stimulated lymphocyte, a reduction in circulating lymphocyte numbers and alternation T-lymphocyte cytokine secretion as well as B cell proinflammatory cytokine secretion. Concomitant MA use and Human Immunodeficiency Virus (HIV) infection not only enhances immunosuppression associated with HIV but also increases the heart disease occurrence with a coincidentally complication of AIDS or AIDS medications.

Psychiatric and substance dependence comorbidities, sexually transmitted diseases, and risk behaviors among methamphetamine-dependent gay and bisexual men seeking outpatient drug abuse treatment

This article describes psychiatric and substance dependence comorbidities, lifetime rates of infectious disease, and reported high-risk sexual behaviors for methamphetamine-dependent, gay and bisexual men at entry to outpatient drug abuse treatment in Los Angeles. Participants' self-reports of high-risk sexual and drug use behaviors and of history of infectious disease status were correlated with diagnostic information from 155 Structured Clinical Interviews for the DSM-IV (SCID). A total of 82 participants met criteria for lifetime depressive disorders; 44 participants met criteria for lifetime anxiety disorders. Compared to those without psychiatric diagnoses, significant differences were observed in lifetime prevalence of sexually transmitted infections among those who have generalized anxiety disorder (higher rates of genital gonorrhea), specific phobia and major depressive disorder (higher rates of oral gonorrhea), social phobia (higher rates of syphilis) and bipolar disorder, type I (higher rates of HIV). Differences in infectious disease prevalence did not correspond to significantly different rates of high-risk sexual behaviors. Findings indicate that gay and bisexual men seeking outpatient treatment for methamphetamine dependence are likely to experience psychiatric comorbidity and to have high rates of infectious disease, including HIV, syphilis and gonorrhea.

Men who have sex with men and also inject drugs-profiles of risk related to the synergy of sex and drug injection behaviors

OBJECTIVES

Men who have sex with men and also inject drugs (MSM-IDU) are among the groups at highest risk for acquiring and transmitting HIV in Colorado and the US. We conducted formative research and a survey among MSM-IDU in Denver to better understand sexual and drug HIV risk behaviors and how they interact.

METHODS

Formative data were collected with 30 persons who work, live or otherwise interact with MSM-IDU using a semi-structured interview instrument. Survey data on sexual and drug risk behaviors were collected with 100 MSM-IDU; eligible participants have had sex with men and injected drugs within the past six months.

RESULTS

Results from formative research were used to generate the survey instrument. The survey results demonstrate high-risk sexual behaviors with multiple partners of both genders; 82% of the sample had primary and non-primary male partners, 20% had non-primary female partners, and 15% exchanged money or drugs for sex. Condom use was inconsistent and infrequent for all types of sex (vaginal, anal and oral) and with all types of partners. Drug risk behaviors highlight that the injection drugs of choice for this sample (90% shoot cocaine and 59% shoot methamphetamine) stimulate sexual desire and cocaine injection increases opportunities for injection risk behavior. Forty-five percent of the sample were HIV-infected. Significant differences between HIV infected and non-infected men were not observed with regard to many sexual and drug risk behaviors.

CONCLUSIONS

These data show that MSM-IDU are engaging in multiple risk behaviors that may have a synergistic effect on HIV transmission, and that their injection drug of choice contributes to their risk. That there do not appear to be consistent differences in preventive behaviors between men with or without HIV infection suggests a greatly increased risk for HIV transmission in this group of men and their partners. Because MSM-IDU do not identify strongly with either MSM because they may not gay identify or IDU because they do not use heroin, targeted HIV prevention strategies for this group are urgently needed.

Anthropological perspectives on alcohol and drugs at the turn of the new millennium

This introduction to the collection provides our thoughts on where alcohol and drug studies in anthropology are going as we enter the new millennium. After commenting briefly on each of the papers that comprise the rest of the volume, we discuss what we see as the most important and exciting issues in the future and give our views on what alcohol and drug studies can offer to medical anthropology, anthropology writ large, interdisciplinary and multidisciplinary research, and the realm of public policy and practical affairs. We call for a continued study by anthropologists of the whole array of pharmacologically active substances used by humans in different parts of the world, whether or not such studies are situated within medical anthropology. We note that many of these substances have received little attention from anthropologists to date, quite strikingly so in the cases of substances such as marijuana and methamphetamines. We emphasize that most scholars working in the anthropology of alcohol and drugs are concerned with the application of their findings to social problems, and we note that this has been especially true of research on alcoholic beverages and injection drugs. This leads us to a discussion of anthropology's involvement in public health intervention and policy work in a variety of settings. Such involvement is shown to have informed anthropological theory (notably political economic approaches) and to have enriched the methodological toolkits and forms of data analysis anthropologists use. Perhaps more importantly, we argue that such multidisciplinary involvement in applied work is most likely to eventuate in theoretical progress in alcohol and drug studies, since theory in the social sciences is not bound to singular disciplinary approaches. Thus we advocate for a "hybrid vigor" in this specialty area in the years ahead.